Surg Today Jpn J Surg (1994) 24:815-818

Case Reports

S U R G E R Y T O D A Y

© Springer-Verlag 1994

Non-Hodgkin's Lymphoma of the Gastric Stump Developing 9 Years After a Distal Gastrectomy for a Peptic Ulcer: A Case Report and Review of the Literature

KAZUYUKI HONDA, 1'2 FUMIAKI WATANABE, 2 TADASHI NOMIZU, 1 YOSHIO YAMAKI, 1 ATSUO TSUCHIYA, 2 and RIKIYA ABE 2

1 Department of Surgery, Hoshi General Hospital, 2-1-16 Oumachi, Koriyama-city, Fukushima, 963 Japan 2 Second Department of Surgery, Fukushima Medical College, 1 Hikarigaoka, Fukushima-city, Fukushima, 960-12 Japan

Abstract: We report herein the case of a 65-year-old man who developed non-Hodgkin's lymphoma of the gastric stump 9 years after undergoing a distal gastrectomy for a gastric ulcer. The patient presented with epigastric discomfort, and an upper gastrointestinal series and gastroscopy revealed a lymphoma lesion located close to the site of his gastro- duodenal anastomosis. A total gastrectomy was performed, followed by combination chemotherapy, comprised of vin- cristine, Endoxan, prednisone and Adriamycin (VEPA). His- tologically, the resected specimen was diagnosed as non- Hodgkin's lymphoma. The patient has remained well without any signs of recurrence for 18 months since his operation. Although there have been a number of reports of adenocar- cinoma devoloping in the gastric stump following surgery for peptic ulcers, the development of malignant lymphoma under such conditions is rare. Following the presentation of this case, we review the available literature and discuss the pos- sibility of malignant lymphoma developing in the gastric stump.

Key Words: gastric lymphoma, complication of gastrectomy

Introduction

There are a number of reports Oil gastric stump can- cers, 1 and the possibility of distal gastrectomy for benign diseases increasing the risk: of cancer develop- ing in the gastric stump has been discussed. 2-4 The results of experimental and clinical studies indicate that duodenogastric reflux may be responsible for the development of adenocarcinoma in the remnant stomach. 5-7 Moreover, the incidence of gastric lym-

Reprint requests to: K. Honda (Received for publication on Feb. 15, 1993; accepted on Mar. 4, 1994)

phomas has increased and now accounts for 1%-8% of all gastric malignancies, 8'9 the stomach being the most common site of extranodal lymphoma. 10,1! How- ever, malignant lymphoma in the gastric stump is quite rare, and only nine cases including that of our patient, have been documented in Japan. 1a-19 We present the case of this patient herein, followed by a review of the literature.

Case Report

A 65-year-old man was admitted to our hospital to investigate the cause of ePigastric discomfort. At the age of 56, he had undergone a distal gastrectomy with a Billroth-I anastomosis for a gastric ulcer, and since then he had been asymptomatic and in good health for 9 years. There was no family history of cancer. On admission, the patient had tenderness over the epigastric region, but no nausea, vomiting, fever, weight loss, or lymphadenopathy were evident.

Laboratory findings showed a white blood cell count of 7,700/mm 3, a hemoglobin of 12.6g/dl, a red blood cell count of 399 x 104/mm 3, a hematocrit of 37.8%, a serum total protein level of 6.4g/dl, and an elevated erythrocyte sedimentation rate of 69/103 mm (1 h/2 h). Urinalysis, serum electrolytes, and biochemical results were within normal limits.

The tumor markers were as follows: carbohydrate antigen 19-9 (CA19-9), 62.5U/ml (normal <37.0), carcinoembryonic antigen (CEA), 3.1ng/ml (normal <5.0), immunosuppressive acidic protein (IAP), 1,340gg/ml (normal <500), and tissue polypeptide antigen (TPA), 57.7U/1 (normal <100).

A chest X-ray was unremarkable, but an upper gas- trointestinal series demonstrated a distensible gastric remnant with irregular thickening of the wall on the lesser curvature (Fig. 1). Gastroscopy subsequently revealed a protruding tumor on the lesser curvature

816 K. Honda et al.: Lymphoma of the Gastric Stump

Fig. 2. Resected specimen of the stomach showing an ul- cerating protruded tumor (8 × 11 cm) on the lesser curvature

Discussion

Fig. 1. A double contrast picture shows giant rugal folds and deformed cardia of the gastric stump in which lymphoma had developed after a Billroth-I anastomosis

of the stomach near the site of the gastroduodenal anastomosis, with diffusely hemorrhagic and friable mucosa. Histological examination of the endoscopic biopsy specimens indicated malignant findings. A com- puted tomography (CT) scan of the abdomen showed an ill-defined mass involving the lesser curvature of the gastric stump.

A laparotomy was performed, which revealed an indurated mass in the lesser curvature of the gastric stump, with enlarged adjacent lymph nodes; however, the liver, pancreas, and other organs seemed not to be affected. A total gastrectomy with splenectomy and lymph node dissection was performed, followed by a Roux-en-Y anastomosis. The resected specimen con- tained an ulcerated protruding tumor (8 x 11cm), with slight invasion to the serosa (Fig. 2). Histological examination revealed an infiltration of lymphoma cells with metastases to the lymph nodes, and immunohisto- chemically, the tumor cells were positive for LCA and LN1. A pathological diagnosis was made of malignant lymphoma of the stomach, (B-cell lymphoma, diffuse, large-cell type) (Fig. 3). A course of postoperative chemotherapy, comprised of vincristine 1 mg, Endoxan 500mg, prednisone 30mg, and Adriamycin 60mg (VEPA), given five times, was administered and he has remained disease-free for more than 18 months since his operation.

Gastric stump cancer, which is defined as cancer that has developed in the gastric remnant following gas- trectomy for benign or malignant disease, 1 is not un- common. When gastrectomy was performed to remove a malignant lesion, however, the tumor may be a recurrence of the primary malignancy. To assess the characteristics of gastric stump cancer, many authors have agreed that the disease-free interval after gastrec- tomy should be 5 years for benign disease, and 10-20 years for malignant disease. 5'2°'21 According to pre- viously reported series, most gastric cancers are adeno- carcinoma, whereas only nine cases of malignant lymphoma of the gastric stump including that of our patient have been documented in the Japanese litera- ture (Table 1). 12-19 In fact, malignant lymphoma of the stomach is relatively uncommon, constituting only about 1%-8% of all gastric malignancies. 8'9 The aver- age age of the nine reported patients was 60.1 years, with a range of 46-74 years, and the male to female ratio was 6:3. All of these patients had undergone surgery for a gastric or duodenal ulcer. The recon- struction methods used after distal gastrectomy were the Billroth-I method in five patients and the Billroth- II method in four. The most frequent symptom re- ported was epigastric pain, while weight loss, general fatigue, nausea, belching, and early satiety were also documented.

The radiographic findings of malignant lymphoma in the gastric stump were quite similar to those of cancers of the unoperated stomach; such as enlarged rugal folds, irregular thickening of the wall, and prominent submucosal nodules. 12'13 The diagnosis of malignant lymphoma on biopsy may be difficult; in fact, only

K. Honda et al.: Lymphoma of the Gastric Stump 817

Fig. 3. Microphotograph of non- Hodgkin's lymphoma of the gastric stump. There was infiltration of lymphoma cells with round or cleaved nuclei (H & E×9)

Table 1. The nine reported cases of malignant lymphoma of the gastric stump

Age/Sex Treatment Case (years) Primary disease Reconstruction Interval method Histology Prognosis

1. 53/M Gastric ulcer Billroth I 11y Autopsy reticulum cell Death sarcoma

2. 71/M Gastric ulcer Billroth I 13y Total gastrectomy reticulum cell 2y Chemotherapy sarcoma

3. 52/M Duodenal ulcer Billroth II 16y Total gastrectomy histiocytoid unknown lymphoma

4. 60/M Gastric ulcer Billroth II 23y Total gastrectomy follicular lymphoma 3y6m mixed type

5. 49/M Gastric ulcer Billroth II 12y Total gastrectomy diffuse lymphoma alive large-cell type at 6m

6. 46/F Gastric ulcer Billroth I 19y Total gastrectomy diffuse lymphoma unknown large-cell type

7. 71/F Gastric ulcer Billroth I 20y Total gastrectomy diffuse lymphoma ly3m Chemotherapy large-cell type

8. 74/F Gastric cancer Billroth II 30y Total gastrectomy diffuse lymphoma lira medium-sized cell or mixed type

9. 65/M Gastric ulcer Billroth I 9y Total gastrectomy B cell alive Chemotherapy diffuse lymphoma at 18m

large-cell type

Y, years; m, months

three patients were diagnosed preoperatively by biopsy, while the others were diagnosed postopera- tively or at autopsy.

Total gastrectomy was performed on eight patients, four of whom were given postoperative adjuvant chemotherapy. Treatment for malignant lymphoma of the gastric stump should be undertaken in a multi- disciplinary manner, using surgery, chemotherapy,

and radiation therapy, not only for advanced cases, but also for patients in Stage I and II. 19 Intensive follow-up to detect any signs of local recurrence and systemic metastasis is essential. 19 Our patient received adequate postoperative chemotherapy (VEPA) and is still alive more than 18 months after his surgery.

There have been a number of studies conducted on the risk of cancer developing in the remnant stomach.

818 K. Honda et al.: Lymphoma of the Gastric Stump

His to log ica l s tudies of the gastr ic s tump showed mucosa l changes , such as a t roph ic gastr i t is , po lyps , and in tes t ina l me tap la s i a , 5'6 and it has been sugges ted

tha t the p o s t o p e r a t i v e a t roph ic gastr i t is caused by bi le reflux and d u o d e n a l conten ts are r e spons ib le for mucosa l me tap l a s i a and subsequen t ma l ignan t t rans- f o rma t ion wi thin the gastr ic r emnan t . 5'6 Masson et al. sugges ted that p a n c r e a t i c o d u o d e n a l secre t ions may act ivate o the r ca rc inogens such as bac te r ia l r educ t ion n i t ra te . 22 Meanwhi l e , Sigal et al." sugges ted tha t lym-

p h o m a s m a y deve lop f rom lymphocy t i c infi l t rate caused by chronic mucosa l in f l ammat ion or u lce ra t ion ,

th rough i m m u n o h i s t o c h e m i c a l and gene r ea r r ange - men t s tudies . 23 H o w e v e r , a poss ib le re la t ionsh ip be-

tween these p red i spos ing factors and the d e v e l o p m e n t of nonep i the l i a l tumors , such as ma l ignan t l y m p h o m a , has not been discussed in the l i t e ra ture .

In conclus ion, m a n y repor t s on gastr ic s tump can- cers and on s tudies re la t ing to the r isk of cancer devel- o p m e n t in the r e sec t ed s tomach have been docu- m en t ed ; however , ma l ignan t l y m p h o m a of the gastr ic s tump is very rare , and the re a re few w e l l - d o c u m e n t e d cases in the l i t e ra ture . Never the les s , it is i m p o r t a n t to be aware of the poss ib i l i ty of ma l ignan t l y m p h o m a even in the gastr ic s tump.

References

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